History and development of medical studies at the University of Witten/Herdecke – an example of “continuous reform”

Introduction: The University of Witten/Herdecke (UW/H) was founded in 1982 as the first privately run German university. In addition to economics, dentistry, a center for life sciences and the institute for general studies, the main focus from the inception of the University was the development of a model course in medical studies. Methodology: A description of the history of the development of medical studies in relation to the reasons for its founding, its founding ideals and their implementation; phases of development, transformations and influencing factors are presented in detail. External assessments are also used for this purpose. Result: The “Herdecke Model” was first implemented with the initial group of medical students in 1983. In the past 36 years the curriculum for medical education in Witten/Herdecke has evolved to meet internal and external requirements. The goals of the founders for a reform of medical studies and the founding ideals of the UW/H have continued to lead the University through a continuous reform process of medical training. From the first model of a reform degree course at UW/H 1983 to the current Model Study Course/Modellstudiengang (MSG 2018plus), these reforms have manifested themselves in four major phases spanning a 15 year period. Landmarks of the reforms include the first systematic introduction of problem-oriented learning in Germany, and clinical and practical training with real patients in both clinical and general medical elective blocks that far surpass the Medical Licensure Act’s requirements. Additionally noteworthy are the introduction of PY training wards and the active participation and co-design role students may hold. Discussion: Due to the small size of UW/H, reforms can be tested quickly and implemented with ease and flexibility. This facilitates a “laboratory setting” for the testing of future-oriented innovations. The small size has allowed various concepts to be able to be used as models, thus serving as stimuli for larger change in medical studies in Germany.


Foundation of the university and planning of reform-oriented medical studies
The concept for the foundation of Witten/Herdecke University (UW/H) as a newly conceived private university that is largely independent of state regulations goes back a long way. It emerged in 1945/46 from an anthroposophical student group in Tübingen, which formed immediately after the catastrophe of the Second World War. Gerhard Kienle was the founding spiritual leader of the group, retaining this role until his death in June 1983. In Kienle's view both the experience of the barbarity of war, and the knowledge of the cruel medical practices that treated people solely as scientific objects demanded a clear counter-model. The central concern was the "development of culturally effective institutions that can facilitate free intellectual life" [1]. With regards to the healthcare system this would allow focusing on the dignity and individuality of the sick person. A milestone along the journey to implement reform-oriented medical education was the opening of the "Gemeinschaftskrankenhaus Herdecke" in November 1969. The Hospital implemented a structural emphasis on interprofessional cooperation on the basis of patient-centered anthroposophical medicine [2]. This impact was accompanied by fostering international academic cooperation: in 1973 a symposium entitled "Toward a Man Centered Physiological Science and Medicine" took place in Herdecke with the participation of internationally renowned scientists [ [3] and [4], p. 506]. In 1976 the Free European Academy of Sciences was founded [ [4], p. 509]. The development of a new type of medical studies was birthed from this foundation. This same year -still without state approval -a preparatory medical course began which initiators (even in 1976) dubbed a "model study course" [ [4], p. 509]. Political resistance and formal legal reasons prevented the University from opening during these years. However the participants pursued their common goal with great commitment, and were able to successfully convince important decision makers in politics and business in the years following. Shortly after the opening of the University but before the first cohort of medical students could begin their studies, Gerhard Kienle fell ill, and died soon afterwards. Konrad Schily was appointed President of the University from 1983-1999 and 2002-2004, thus became instrumental in the implementation of the University project [5].

Implementation of the reform concept
Since the opening of the University 36 years ago, its guiding principles have encouraged the involvement of all stakeholders and interest groups, the students in particular. The appreciation of differing perspectivesat times through vigorous discussion -has allowed for a continuous and widely supported reform process.

"Freedom, truth and responsibility" as the foundation of continuous development
At the Dean's Symposium in Munich on 18 October 1982, Gerhard Kienle stated the following regarding the founding reasons and methodically guiding ideals for the continuous development of scientific studies at Witten/Herdecke University of (UW/H): "Truth, freedom and social responsibility in their full unconditionality are the Herdecke model." [[6], p. 354]: • The pursuit of truth is understood as an expression of an "unconditional love for the cause" [ [6], pp. 70-71]. • The guarantee of personal freedom is named as a condition and prerequisite for scientific work in research, teaching and university studies. • Ultimately, social responsibility consists of aligning one's pursuit of knowledge in such a way that it will benefit others, and strengthen and promote the value and dignity of fellow human beings in society.
These values remain central to the University's curriculum. The triad of the basic curriculum tenets are knowledge, skills and values. It is values and attitudes that are given the most importance. The centrality of these basic values highlights how seriously they are honoured.

Controversy as the engine of a beneficial development
Soon after UW/H was founded in 1985, the first signs of conflict emerged around the introduction of modern teaching and learning methods. This tension arose between the more interdisciplinary vision of the Deanery and the more subject-oriented vision of the departmental representatives. Robert Wiedersheim, the then Dean of the Medical Faculty and former WHO department head for Health Manpower Development [7], moderated the development and change process. Wiedersheim deemed this process necessary and involved not only the departmental representatives, but above all the students. Wiedersheim considered the controversy implied in the process as essential to aid the development of a modern curriculum that was broadly accepted across the entire faculty. He introduced the curriculum designers of the University to an international network of reform universities: McMaster (Canada), Maastricht (The Netherlands), and Linköping (Sweden). Furthermore, he introduced them to international forums on questions regarding medical education (AMEE, GMA) and sought contact with the "Murrhardt circle" [8], [9]. The inclusion and appreciation of differing interests and perspectives has remained a key factor of the University's development and change processes in ensuing years.

Students as co-designers and co-responsible people
The "Witten Didactics" had repeated and significant design input from the students who also supported and further developed the implementation. Students in Witten were and are encouraged and empowered to take responsibility for the continuing development of the university.
The general willingness to co-design and assumption of responsibility is -in addition to motivation for medical studies, suitability and ability to reflect -one of the criteria in the UW/H selection process. This conferred responsibility is exemplified by the involvement of experienced students in the selection process, in teaching, in curriculum development and in committee work at all levels.
Through the StudierendenGesellschaft (a non-profit organization), students form part of the University's shareholders and manage the entire tuition fee financing arrangement. This allows for a free medical degree course while studying by means of a reverse generational contract. The StudierendenGesellschaft is the direct "mouthpiece of the students in the highest commercial body of the University -a first in Germany.

Privacy and small size
With the goal of having the greatest possible freedom in university design, UW/H embarked on a path of non-profit privacy. This enables the University to implement new ideas regarding content and methodology comparatively quickly and easily, without being shackled to the state. However, this path also means that funding for expensive medical education has to be secured year after year, thereby providing a limited economic framework: "Out of money we have always been." (Konrad Schily). The scarcity of funds in 1995 required students to assume responsibility for the entire organization in the form of a financial contribution. This led to the foundation of the purely student-run StudierendenGesellschaft, its aim being to provide tuition independently through a reverse generational contract, regardless of varying family incomes.
The small size of UW/H is a necessity to ensure affordability, yet simultaneously desirable in order to facilitate personal discussion between learners, teachers and employees.

Results
The In order to be able to provide the necessary "individual assistance" [10] for patients after completing their studies, training at the UW/H aims to make the competences actually required in medical practice tangible and learnable. The authentic context of patient contact is implemented through the integrated Perceptual Internship, the continuous General Practice Internship and the comprehensive Clinical Elective Blocks (a total of 54 weeks).

2. The training of perception, cognition and judgment
In addition to experiencing medical practices, the ability to critically reflect on one's own thinking and cognition as the basis for medical power of judgment and scientific faculty is the second cornerstone of Witten Didactics. The cross-disciplinary "studium fundamentale" (general studies) runs for an entire day each week for the duration of each semester and offers a space for practice, reflective thinking and cognitive activity with respect to liberal arts, the sciences an philosophy.

Personality and personal development
The importance of personal development is the third cornerstone of medical studies at UW/H, as both a personal training goal and in the interactive and exchangeoriented University organizational development. It is strongly anchored in the general studies unit, the artistic and reflexive courses, and through scientific debate of epistemological, philosophical and historical issues. Individual design ideas, personal engagement and students' energies are all embedded into UW/H's develop-ment at both an organizational and curriculum level. This co-design role combined with a patient-centered curriculum creates a healthy development of students' abilities. Most importantly, students learn the values and attitudes necessary in order to be able to adequately meet occupational and individual challenges. The previously established practice of regular internships in GP surgeries was further developed into a "GP Adoption Program". This ran for the first semester onwards for a total of 5 weeks. The students received section-related tasks which had to be documented in a portfolio. Alongside the POL cases, GP consultation hours relating to the subject matter were introduced once a week.

Cornerstone 2: Longitudinal range of courses
A continuous, longitudinal range of courses were developed in four integrated curricula; communication, science and research, ethics, and health care systems and economics. These were combined with existing comple-mentary optional formats from the field of integrative medicine, such as accompanying studies in Traditional Chinese Medicine (TCM). In addition, a student-initiated homeopathic working group began to draw increased attention, whilst preparation for the United States Medical Licensing Examination (USMLE) was introduced as a formal offer.
In 2004 the Integrated Complementary Studies in Anthroposophic Medicine/Integrierte Begleitstudium Anthroposophische Medizin (IBAM) was introduced. It holds a special role due to its comprehensive design as an optional offer, its research training, and its search for innovative training formats. It seeks to supplement scientific methodology in medicine with idealistic philosophy, a spiritual view of humanity [12], and implementation of training formats with humanist characteristics [13]. Furthermore its aim is to research and test the contribution of anthroposophic medicine to the development of medical training and medicine as a whole [14]. The content of the IBAM is closely linked to the content of the central curriculum and integrates longitudinally into regular medical studies [15].  [16]. Medical graduates (1996)(1997)(1998)(1999)(2000)(2001)(2002) who had graduated at least two years previously were interviewed online by the CHE. The UW/H graduates were found to be older, spent more time abroad, and were involved more frequently in clinical training. Nine questions related to professional medical practice were included in the survey and evaluated comparatively. UW/H graduates rated their medical studies as better in terms of independent learning and work, psychosocial skills, practical medical skills, teamwork, problem-solving skills, and interdisciplinary thinking. However, they judged their medical knowledge and scientific competence as inferior in comparison. The University was evaluated by the Science Council in 2005/06, 2011 and 2018 [17], [18], [19], [20]. In 2014, the Science Council issued recommendations for the further development of medical studies in Germany by way of an inventory of human medical model study courses . In an overall assessment, Manfred Prenzel summarized as follows: "All in all, the model study courses make a significant contribution to the development of medical studies in Germany. The introduction of the 'model character' framing has triggered a continuous process of change. It has allowed -also with regard to the reform of standard degree courses -creativity and a desire to shape faculties differently. The 'model character' framing can therefore be regarded as a success with regards to the expectations placed on it." [https://www.wissenschaftsrat.de/ download/archiv/pm_2114.pdf] The assessment evaluated nine model courses, the largest observation period taking place at the University of Witten/Herdecke [21]. The MSG 2000 was assessed positively by the Science Council as part of a University-wide assessment. Council President Professor Wolfgang Marquardt stated the MSG 2000 was exemplary and could play a pioneering role for the whole of Germany [22].
In 2013, the model study course was awarded the Hartmannbund Faculty Prize for the best medical training, a prize that is awarded based on a nationwide online student survey [23]. Classes are evaluated by the students online at the UW/H at the end of each semester. Both the lecturers and the students who participated in the evaluation can access the results. The Vice Dean for Teaching then receives the raw data for further internal faculty evaluations. Furthermore, the evaluation results are used for leadership discussions between the Dean and the professors, and in addition for the further development of the degree courses.
The above mentioned procedures are supplemented by semester-wide feedback interviews with students, and evaluation of the logbooks from the clinical elective blocks. The results are reported back to the lecturers and examiners, and discussed in cross-site subject area conferences.
In internal evaluations in 2013, students at UW/H rated the contribution of the medical general studies unit as good in terms of personal development, and as satisfactory with regards to technical and professional topics.

The fourth Witten Model Study Course 2018 plus -Developing health together
The renewed reform considerations for the Model Study Course/Modellstudiengang (MSG 2018 plus ) were guided by a process-oriented view of the basic concepts of the medical system [24]: A person's health, illness, suffering and healing are not seen as static states, but rather as dimensions of dynamic processes that require an integrated view of biological, mental-spiritual and societal social processes. Thus, the promotion of health is equal to caring for the sick. The conceptualization of future-oriented medical studies should therefore anchor around an integrated health care and health promotion system, which is multi-professional, team-based, patient-centered, process-oriented and increasingly out-patient-based and change-driven [25], [26].

Educational goals of MSG 2018 plus -Gradual assumption of responsibility in real-life contexts of medical care provision
The Model Study Course/Modellstudiengang (MSG 2018 plus ), supplemented its previous training goal of ''...a medical person capable of lifelong learning'', with "...a medical person capable of lifelong learning and acting". Therefore the curriculum should not be solely based on an experiential spiral of knowledge and learning, but rather in addition embrace a spiral of action -in the sense of capacity for creative work and the ability to shape things [26]. The MSG 2018 plus integrates comprehensive self-designed learning spaces (longitudinal care for a patient, mentoring, peer teaching, track offers, etc.) with an underlying theoretical and practical clinical ability to act as a doctor. Practically speaking, this ability to act above and beyond the original elements of the model study course is achieved by gradually increasing the assumption of responsibility in real-life care settings of out-patient and inpatient elective placements.

Strengthening the cross-curricular, longitudinal thematic priorities
In

TP 1: Outpatient health care
Outpatient health care was redesigned in the MSG 2018 plus . The early contact with GP care in the first semesters of study, which had proven viable in MSG 2000, has been further extended to include out-patient facilities, so-called "outpatient learning venues" (pediatrics, orthopedic surgeries, out-patient rehab, health authority offices), and "longitudinal care for a patient". Interested students also have the choice to deepen their experience of primary care in three four-week "outpatient health care" tracks (see below).
In this longitudinal curriculum, all previous elements of personal development are integrated and expanded. The goal is the development of an all-round professional person who cultivates skills in communication, reflection, teamwork and self-development. Practice and reflection are important experiences and tools on the path to lifelong development and self-education.

TP 3: Interprofessional Education (IPE)
A longitudinal offer of interprofessional courses with students from other health care professions satisfies the goal of UW/H to achieve effective interdisciplinary cooperation of all professions involved in health care. Joint courses (POL tutorials, patient examination courses and clinical consultations) with students of physiotherapy, health and nursing, speech therapy, etc. are designed and implemented at both the pre-clinical and clinical phase.

TP 4: Working Scientifically
The area of "working scientifically" will be significantly expanded in MSG 2018 plus . Two six-week periods will focus on this topic, while other longitudinal events intensify training of this subject matter. Interested students are again given the opportunity to deepen their insights by taking the research track (see below).

TP 5: Health system and care structures
An interprofessional and exploratory teaching offer will be developed and implemented. This will enable students to familiarize themselves with existing care structures, institutions and professionals in the health sector, to explore approaches to further develop existing care structures (best practice examples), and for the students to develop and present to each other their own models for improving health care. Three to four-week tracks will offer students an opportunity to focus on topics of individual interest more extensively and systematically than the previous model. Currently, tracks are planned for the following five thematic priorities: outpatient medicine, clinical medicine, research, digitalization in health care, and integrative medicine.

Discussion and outlook
The first reform degree course at UW/H in 1983, the Model Study Course 2000, and the Model Study Course/Modellstudiengang (MSG 2018 plus ), all had the common aim of pursuing innovative ways of training doctors, whilst simultaneously contributing to a medical care system that aims to align itself with the dignity and individual needs of each patient and the respective societal requirements. Thus the following points were agreed upon at UW/H as the cornerstones of medical training: 1. The experience of medical practice combined with a gradual assumption of responsibility in the context of real-life medical care; 2. The training of perception, cognition and discernment: including scientific experience and knowledge in science, culture and humanities; 3. The personal development of students enabling them to grasp and reflect on questions of individual and normative attitudes and values.
The question of a timely implementation of core conditions geared toward the dignity of others in a medical education system remains a key challenge for today's healthcare system and medical education. This is currently being discussed in the context of the increasing economization and standardization of medicine [27], [28], [29]. In addition to imparting knowledge and skills, the cornerstones of a medical education system reside in an orientation towards fundamental human values and attitudes. These include granting and safeguarding individual freedom of knowledge formation and reasoning of actions, the search for truth, and the commitment to one's own social responsibility [30], [31]. These institutional ideals have remained unchanged throughout this development. Again and again they provide a compass for the continuous development of education oriented towards the necessities of changing societal conditions and requirements for medicine [32]. Both autonomy and independence from external (including governmental) requirements that the University aspires to are limited as they fall into a wider framework, defined by external conditions. These conditions include State University Law, training regulations, ministerial requirements, conditions of the Science Council, and state examinations. The discussion of these external influences leads to a productive tension which creates an intensive search for compromises and, above all, to quality assurance and benchmarking. The constant challenge of private sector financing has led to a broad shareholder structure and, moreover, to students assuming financial and organizational responsibility. This has led to a high level of identification of the students with the institution, and a shared social responsibility for the future generations of students. This was honored and specifically highlighted by the Science Council in 2011 [ [19], p.14].
From the outset, focus on the dignity and individuality of the patient led to a broader curricular focus on patientcentered medicine and education. This grew into a pedagogy centered on the learner as an individual, who orients oneself towards self-determined and intrinsically motivated learning and development models [33]. However, the teaching of these so-called ''soft skills'' and other general skills (which were originally taught under general studies), did not appear to be specific enough to prepare students for personal medical competence. This observation led to the establishment of an integrated longitudinal curriculum in the first official model course which included a strand entitled "Communication and Ethics". In the development of this strand, the focus in the current MSG 2018 plus centers around "Inner Work and Personal Development" (see above.) Many of these approaches are shaped and implemented with relative ease due to the small size of the faculty and the Department of Human Medicine, the still manageable number of students, a good relationship between teachers and learners, and the combined strength of the communication of those involved. This closeness and personal interaction has also been established at other universities, such as the University of Massachusetts. This has been achieved through the establishment of "learning communities" that enable longitudinal contact between students and faculty. It is therefore feasible at larger universities. The specific conditions for successful application (less focus on school-leaving marks, stronger focus on social commitment, ability to reflect, motivation for study, and specialized didactics) means that the curriculum at the UW/H cannot be directly compared with other universities. In general, students at UW/H are older and have more professional and international experience. Conclusively, studying at UW/H appears to be an excellent preparation for the workplace, particularly with regards to independent learning and work, psychosocial competences, practical medical skills, teamwork, problem-solving abilities, interdisciplinary thinking, and job satisfaction [16]. In its quest for new ways to further develop medical education, the UW/H has evolved over the past 36 years into a University that is part of a network of medical faculties working together on experiential and science-based developments, and in the reorientation of medical education. The UW/H is involved in research and teaching with many regional, national and international partners [34]. The small size and the non-governmental sponsorship of the UW/H opens up space to test and implement various new teaching and curriculum concepts. These can function as "laboratory scenarios" for testing prototypes that benefit state educational institutions [35].